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Redesigning the NHS to cope with chronic illness

Many people of my age, including myself, would not be alive today given the knowledge of medicine that existed when I qualified as a doctor in 1963. The advances in biomedical science and technology have been huge over the last 50 years (1).

 

It is paradoxical that as a result of improvements in treatments and wealth the burden of disability and illness has increased. According to the Department of Health the treatment and care of those with long term conditions accounts for 70 percent of the primary and acute care budget in England. In Scotland the majority of those over 65 years have two or more chronic conditions. People in more deprived areas are worst affected than those in more affluent areas. Mental health problems are strongly associated with the number of physical conditions and people with multiple problems have considerable difficulty with the coordination of their care (2).

What have been termed the diseases of civilisation, obesity, drug dependency in its various forms including smoking tobacco and the use of opioids, mental health problems, social stress etc mean that one of the main issues in the recent general election was spending on the NHS.

What have been termed the diseases of civilisation, obesity, drug dependency in its various forms including smoking tobacco and the use of opioids that has become an epidemic in some parts of the USA, mental health problems, social stress etc mean that one of the main issues in the recent general election was spending on the NHS. In reality NHS spends a similar amount on health care as comparable OECD countries but social care spending has fallen since the financial crisis of 2008; current total spending on health care in the UK is 9.9% of Gross Domestic Product (3).

We need to redesign the NHS to cope with our current problems. The care and treatment of people with chronic illnesses, the improvement of health and reduction of health inequalities should become the responsibility of local councils working with the NHS with joint commissioning of primary care, social care, and community nursing based on the Buurtzorg neighbourhood model (4).

General Practices should be linked to community hubs serving populations of circa 50,000 to 100,000 as joint enterprises with local councils, supporting social care, community support and voluntary services, diagnostic centres with specialist input and emergency medical centres etc (5).

Political responsibility for the service should be shared between national and local government as in Scandinavia and future investment should be targeted at this local level so that the pressure on hospitals can be relieved.

We need to recognise that care and love are sometimes more important than operations

But that is not all. Patients need to be able to take the decisions to decide what care and treatments they want. I am afraid that like Ivan Illich I think modern medical science and technology whilst at times wonderful can also be cruel (6). The main aim of science as Bertold Brecht wrote in Gallileo, is not to achieve infinite wisdom but to avoid infinite error. We need to recognise that care and love are sometimes more important than operations, intensive care and expensive medicines. Working with people, families and neighbourhoods, we need to improve health and well being and help people to make supported choices about how, when and what they want from us.

References
1. The second greatest benefit to mankind? – The Lancet

2. http://www.gov.scot/Topics/Health/Services/Long-Term-Conditions

3. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthcaresystem/bulletins/ukhealthaccounts/2015

4. http://www.buurtzorgusa.org/about-us

5. http://www.parliament.uk/nhs-sustainability
(collated written evidence Cyril Chantler page289)

6. davidtinapple.com/illich/1995_death_undefeated.pdf


Sir Cyril Chantler

Cyril Chantler MD FRCP FRCPH FmedSci is the Chair of University College London Partners, which brings together world-class medical researchers and clinicians from UCL and four NHS hospital trusts, leading research that is driven by patients and their needs. He is a past Chair of the King’s Fund and is a member of the Editorial Board of the Journal of the American Medical Association.